Rev 4/1/13
31 Research Way
East Setauket, NY 11733-9113
631-444-4331
FINANCIAL AID APPLICATION
You may be eligible for financial aid. Please complete this application and mail or bring it to Stony
Brook Medicine Business Office with the requested documentation. We will advise you of our
determination within 30 days of receipt of the completed application. Thank you.
Name of Applicant: __________________________________ Date of Birth: ________________
Street Address of Applicant: _______________________________________________________
City, State and Zip Code: _________________________________________________________
Names and Birth Dates of Family Members Applying: __________________________________
______________________________________________________________________________
______________________________________________________________________________
Home Telephone #: _________________________ Cell Phone #: _________________________
Insurance Information (if any)
Names of Insurance Company: ____________________________________________________
Address: ______________________________________________________________________
ID # and copy of the card: ________________________________________________________
I hereby make application to Stony Brook Medicine, State University of New York at Stony Brook, for
consideration under the Financial Assistance Program.
I certify that the information contained in this application is true and correct and that the
documentation submitted in support of this application, as to earnings and number of dependents is
true and correct.
Signature of Patient or Responsible Party _________________________________ Date _____________
***Please check box [ ] if you are interested in receiving information on the following:
[ ] Child Health Plus
[ Healthfirst
[ ] Family Health Plus
click to sign
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